With the number of COVID-19 cases in the country steadily rising, there are serious concerns about the health of doctors and healthcare workers who are at the frontlines of the fight against the pandemic. Working round the clock, a vast majority of them without adequate personal protective equipment (PPE), these doctors, nurses and caregivers are fighting an uneven battle against the deadly virus which has already claimed close to 60,000 lives globally.

This is a problem common in almost all countries fighting the pandemic. But it is all more worse for a country like India, which has just one doctor for every 1,445 people .

By the government’s own admission, around 50 doctors across the country have tested positive to the deadly coronavirus .

Two doctors and two nurses in Mumbai’s Wockhardt Hospital have tested positive for COVID-19 after attending to a 70-year old patient with cardiac complications. The patient did not show symptoms of coronavirus and was admitted in the cardiac care unit.

The doctors attending the patient were using basic surgical masks and gloves while performing procedures. Wockhardt staff CNBC-TV18 spoke to said that their demands for N95 masks or personal protection equipment for all departments made earlier were rejected by the hospital as limited supplies were reserved for the hospital’s nine-bed COVID-19 isolation ward.

The 70-year old patient eventually tested positive for COVID-19 and died on April 1.

The Mumbai Central facility of Wockhardt has since been declared a containment zone as unprotected medical staff could have transmitted the virus to other people and patients. All admitted patients and healthcare staff have now quarantined and are undergoing tests to confirm if they have contracted the infection.

The spouse of one of the doctors who tested positive at Wockhardt has also contracted the virus.

A doctor in the Physiology Department at Delhi's All India Institute of Medical Sciences (AIIMS) tested positive too. Two other doctors from Delhi's Mohalla Clinic and others in government hospitals, have found to be COVID-19 positive.

A nurse at Mumbai's Jaslok Hospital who was tending to a patient battling bladder cancer has tested positive too.

These are some of the many instances where doctors or caregivers not directly tending to confirmed COVID-19 patients have been infected. Moreover, the unavailability of PPE kits and most importantly N95 masks have put the entire medical fraternity including doctors, nurses and other staff in danger.

That’s not all, the scarcity of PPE across major states and government and private hospitals is creating further problems for health workers. While the Ministry of Health in a press briefing reiterated that steps have been taken to ensure there is ample supply of PPE for states and hospitals, local authorities have said that the supplies are scarce and have arrived late.

The Delhi Health Minister told CNBC-TV18 that the state has just 4,000 PPE kits and state-level orders were pending. Delhi has further sought around 50,000 PPE kits.

Niharika Barik Singh, Secretary Health and Family Welfare in Chhattisgarh said that the state has less than 5000 PPEs. “We have just been supplied 1,000 PPEs by the central government. We need at least 10,000 right away. Even to expand our scale of testing, our lab technicians need PPEs.”

IAS officers across the country have raised red flags on the non-availability of protective clothing and testing kits. Most districts have reported a shortage of testing kits and PPEs. Only 28.5 percent of the 266 IAS officers said that there were enough PPEs in stock in their respective districts.

As on April 3 (8 pm), India had 2,301 confirmed COVID-19 cases, while 56 people had died due to the virus.

PPEs, N95 masks needed for all hospital staff – not just COVID-19 centres

Although in short supply, PPE kits are being reserved for staff at COVID-19 facilities. In most hospitals, including AIIMS-Delhi that has its own procurement budget, other departments are not being provided protective gear.

A specialist at AIIMS' Neuro Critical Care Department said, “We are being provided locally-made two layered masks. Even surgical masks are not available." A neuro critical care specialist said, some in our department are wearing locally stitched cloth masks.

“I have been wearing an old mask, which has been washed a few times. I don’t know what protection it will provide, I add one more layer of covering and use it. But we are still reporting to work,” he added.

Another doctor in AIIMS said that nurses and paramedics in other departments have been given cloth masks and most of the staff are scared to interact with patients.

A junior doctor in a government hospital in Patna said that almost 90 percent of the patients are just carriers of the virus, are asymptomatic. Till they are tested we won’t know. “We are being exposed to them. We are wearing two-three layers of surgical or 3-ply masks while screening patients, but those collecting samples are the most scared.”

Both private laboratories and government centers have elaborated in difficulties to expand testing and swab sample collection due to lack of PPEs.

Availability of protective gear in mid-tier towns and cities is a major problem. Doctors on rotational shifts at the OPD of Jamshedpur’s Civil Hospital were initially provided with cotton masks. The regular OPD was closed and a few doctors were posted at the cough and cold clinic to screen suspected patients.

A doctor here said that most of us had bought their own three-ply masks/SSP masks which they use along with surgical masks as the only protection tool. The hospital had tested around 149 suspects, however, most have tested negative and a few reports are awaited.

Civil surgeon Dr Maheshwar Prasad reiterated his difficulty in allocating limited supplies of N95 masks and PPE kits, “I don’t have much PPE kits, and can’t utilise them on regular days. I have to save it for isolation wards and swab collections. We are hopeful in a day or two we will be receiving a supply of 100 PPEs and a batch of N-95 masks.”

Poor quality PPE at coronaviurs centres

Availability of PPE is a critical issue, so is quality. The government through its HLL unit has started distributing some PPE kits and masks to facilities, but doctors at centres are questioning the quality of the supplies.

A video from a doctor at Lok Nayak Hospital went viral on Twitter a few days back. His video showed “low quality PPEs” that were so porous that water could easily pass through it.

A critical care specialist at Nalanda Medical College and Hospital in Patna, who did not wish to be identified, told CNBC-TV18 that until now the team was working with HIV kits. It was only three days back that 10 PPE kits were supplied for the ICU. However, the quality of those PPE kits was not satisfactory.

The masks supplied as part of the PPE kit are not N95, but three layered surgical masks. Doctors are wearing two surgical gloves to reduce the chances of infection. The rear of gowns or coveralls’ are open and they do not have proper hoods. The head caps do not cover the forehead and neck properly. Doctors have to wear personal scarfs to cover their heads. Shoe covers also do not solve their purpose.

PPEs provided at NMCH, Patna.

Some healthcare workers were asked to wash and reuse their scarfs made of semi-synthetic material.

NMCH has been declared a COVID-19 hospital in Patna and currently has six positive patients and 11 suspected patients. One of the doctors at the hospital said, “What we have been given is for limited protection. We need PPEs for highest protection, especially for those who work in ICU who perform procedures on critical patients.”

Multiple doctors in Bihar, Jharkhand and Delhi that CNBC-TV18 spoke to reiterated the issue about poor quality PPEs.

PPE kit at NMCH, Patna.

A specialist at AIIMS-Patna said that the hospital has PPE kits to last the next 10 days. The actual lot is from a year-old procurement that the hospital had ordered as part of a regular tender. “A few PPE kits have been received from HLL now, they seem to be of reasonable quality.”

AIIMS-Delhi centre has received Hazmat suits, the most advanced protective gear, and reportedly the COVID-19 center now has adequate supply. The quality of a few parts have issues, like fogging in glasses which some doctors have complained of.

Dr SP Kalantri, Director and Medical Superintendent of Mahatma Gandhi Institute of Medical Sciences, Wardha said that there is very little awareness about use of PPEs among healthcare staff. Hence, there is confusion about the quality.

Kalantri said that apart from the supply shortage, there are reports of poor-quality PPEs in the market. The state administration has asked us not to purchase PPEs from unregulated markets and wait for government procured supplies. But it is taking time. “Civil surgeons and collectors will procure and deliver. Government supplies haven’t come to us as yet,” he said

The hospital procured a set of 1,500 PPE from a private party donation to the hospital, which has set up a 100 bed facility for coronavirus patients. The supplies from the district administration are yet to come, said Dr Kalantri. “Our stock will last us for another three weeks,” he added.

Government orders

The central government was caught off-guard on medical protective gear as until March 18, India was exporting raw material.

It was only on March 24, a day before the country went into complete lockdown, that state-owned HLL Lifecare, the nodal agency for procurement of PPE kits, floated a global tender. However, bypassing the tender the government on March 30 ordered 21 lakh coveralls from 11 domestic manufacturers.

Orders for 10 lakh PPE kits from a Singapore-based platform and 20 lakh coveralls from a South Korean firm have also been confirmed. Two domestic companies making 50,000 N95 masks a day have also been roped in, with an assurance of expanding production to 1 lakh in a week’s time.

It estimated that India will need 4 million N-95 masks and 1 million coveralls and goggles, among other protective items like nitrile gloves and face shields.

The government is hoping to start supplies from these companies by April 10. The Defence Research and Development Organisation (DRDO) has also got involved in developing bio-suits to protect medical teams from the virus. It is working on expanding its daily production capacity of suits from 7000 to 15000. Many private textile companies are now working on producing PPE coveralls and head caps. DRDO is also working to make N99 masks.

Dr Kalantri said since PPE kits are expensive, hospitals will not be able to afford it from their own budgets; it is the government that will have to provide. “But with HLL being the sole procurer and supplier, there is a good degree of confusion even within HLL. Districts and states liaising with the sole supplier and procuring for hospitals are stuck in a back and forth.”

Dwindling morale

Wockhardt’s entire Mumbai Central facility has been closed for new admissions and all OPDs including dialysis for next 14 days, reducing this healthcare capacity from the system.

Add to that, incidents of attacks on doctors and laboratory professionals.

In some districts, government hospital doctors and nurses refusing to work without PPEs are being given notices for disciplinary action. Most private sector doctors are not operating their clinics.

A public interest litigation (PIL) has been in the Supreme Court seeking directions to avail WHO-approved protection kits for doctors. The centre’s response is awaited.

Almost all doctors and nurses CNBC-TV18 spoke to say they are apprehensive. Many have taken to social media to display their concerns and anger of having to work wearing plastic sheets or helmets as protection against the virus.

The NMCH, Patna doctor quoted earlier said healthcare staff working without proper protective gear are so scared that unfortunately incoming patients are treated as untouchables. Doctors still get some protective gear, nurses, ward boys and support staff are worse off. “Healthcare staff are themselves not feeling secure and protected. What treatment can they provide?”

But most doctors are still performing their duties, working with or without PPEs, in OPDs, cough clinics, isolation wards or ICUs. Assurances from the Central, State and District administration is coming, but not the PPEs.

AIIMS neuro specialist said we are performing our work, but we return to our families and children with guilt. “We understand there are no protocols in a pandemic, and we are working also, but we fear for our families. What if we unknowingly pass on the infection to them?”

A few state governments have made arrangements for stay of doctors in direct COVID care, but not all have been able to arrange a similar facility.